Hopper Health is serving neurodivergent patients in California and New York.

A new healthcare company has launched a digital-first primary care platform to serve neurodivergent adults.

One in five U.S. adults is neurodivergent, with a range of conditions such as autism, attention-deficit/hyperactivity disorder (ADHD), obsessive compulsive disorder, and Tourette syndrome. These adults can struggle in healthcare settings; for example, dense paperwork can overwhelm them and bright lights can lead to anxiety.

Brooklyn, New York-based Hopper Health is serving neurodivergent adults in California and New York. Hopper CEO and founder Katya Siddall-Cipolla told HealthLeaders that she was inspired to create the company from personal experience.

"I am an autistic and ADHD person myself, and I also have Crohn's disease, which is a lifelong chronic illness, and I have spent the past 20 years of my adult life not getting medical care that understands people like me. Whether it is not understanding my sensory needs in a medical environment or communicating differently the way that I might explain or experience pain, I have gotten care that sometimes was not the right care or sometimes was delayed by many years. … For me, the inspiration for Hopper is I do not want my daughter's generation to go through the things that my generation has had to go through to get to some semblance of health," she said.

Siddall-Cipolla said there are two primary elements to providing quality care for neurodivergent adults.

"One is clinicians understanding the population, being very curious, being collaborative with patients, and understanding that they must take time and energy to deeply understand what is going on because if they operate at the surface level, oftentimes they might miss cues that neurodivergent people are sending that are important from a diagnostic perspective. The other piece that is incredibly important is the peer support component. Many neurodivergent folks like myself struggle with executive functioning—things like planning, task follow-through, and following steps in a certain order. So, the red tape of healthcare such as insurance, specialist visits, and who is in network and out of network is so challenging that oftentimes people like me will just avoid care and shut down. The peer navigation component is designed to be the support system for health for the individual patient," she said.

Clinicians selected to cater to neurodivergent adults

Hopper clinicians offer culturally competent care, Siddall-Cipolla said. "One thing we have done is we want to be neurodivergent-affirming, which means we need to understand the experience of neurodivergent people. We need to be thoughtful of sensory needs, information processing, and communication differences. In addition, all of our providers go through a training process for people of color as well as LGBTQ and transgender issues so that they have a broader perspective on inclusion. Unfortunately, there are a lot of neurodivergent folks who are multiply marginalized, and they have the least access to care and tend to have the lowest success rates finding clinicians who can understand them."

Hopper offers contextual primary care, she said. "Context is the patient's environment and experience—it is what is happening with them. We are saying that we are meeting people where they are instead of expecting them to come to where we are. We are wanting to understand all of the context around a person's experience, so that we can accommodate them appropriately in a healthcare setting, versus saying, 'This is how you must show up. This is how you must access care. This is our process.'"

Peer navigators

Peer navigators are a key aspect of Hopper, Siddall-Cipolla said. "Our navigators have been through health challenges. Our navigators have dealt with the mental health system. Our navigators live challenges every day, and they also have the additional education around the healthcare ecosystem as well as how all the parts and pieces fit together at a level that most patients do not have."

The navigators can help neurodivergent patients with tactical healthcare challenges such as prior authorization for medication as well as other issues, she said. "They can also help with things like asking for accommodations at work, or things like getting an MRI. For patients who have never had an MRI, our navigators can tell the patients about accommodations they can reasonably ask for at the imaging center. Navigators can call ahead and have conversations with office staff for other types of visits to make sure our patients are understood even before they walk in the door. They do advocacy work on top of the navigation component."

Visit length and financial model

At Hopper, telehealth visits are usually longer than typical primary care visits, Siddall-Cipolla said. "Our first 'welcome' visit with each patient is a full hour with their primary care provider. Prior to that full hour, patients have an opportunity to connect with their navigator, talk through some of their challenges, and give more context. So, by the time the patient sits down with the clinician, the clinician has a ton of contextual information about the patient's life, and the clinician has time to ask questions. … A typical urgent care visit is anywhere from 20 to 30 minutes, depending on the issues. There is time with the patient and time for good charting and documentation as well as follow-up."

For now, Hopper is operating with a direct-to-consumer financial model, with patients joining monthly or annually. The monthly fee is $99. Hopper hopes to establish relationships with payers soon, she said. "The near-term goal is to be in a capitated model with payers. We want to offer true value-based care and take on risk for managing our patients' conditions."

CommonSpirit Health has launched several efforts that target cardiovascular care in maternal health.

CommonSpirit Health is stepping up efforts to address cardiovascular disease in maternal health.

In several reports, the United States has the highest maternal mortality rate compared to other developed countries—a report from The Commonwealth Fund found the United States had the worst maternal mortality rate compared to 10 other developed countries. According to a Centers for Disease Control and Prevention (CDC) report, the U.S. maternal mortality rate rose from 20.1 deaths per 100,000 live births in 2019 to 23.8 in 2020. The CDC report highlighted a racial disparity, with the maternal mortality rate for Black women at 55.3 deaths per 100,000 live births, which was nearly three times higher than the rate for White women.

A new report from the CDC shows that the U.S. maternal mortality rate rose 40% from 2020 to 2021.

Addressing cardiovascular disease during pregnancy is crucial to reducing maternal mortality, says Rachel Bond, MD, system director of women's heart health at CommonSpirit. "Cardiovascular death, which is the leading cause of death during pregnancy, is preventable 80% of the time. A lot of that has to do with us communicating with each other and diagnosing these conditions early."

CommonSpirit has established a Maternal Heart Council to educate patients and clinicians about cardiovascular health during and after pregnancy as well as to provide guidance and protocols, she says. "We are getting guidance from both cardiologists who specialize in high-risk pregnancies as well as cardiologists from subspecialty services. So, in the event that we need interventional cardiologists, advanced heart failure cardiologists, or cardiologists who come from other specialties such as electrophysiology where we may have an abnormal heart rhythm, they are incorporated within the Maternal Heart Council. We work collaboratively with the primary obstetrician as well as the maternal fetal medicine provider, who is a high-risk obstetrician."

The Maternal Heart Council is led by physicians and includes advanced practice providers, nurses, and hospital administrators, Bond says. "We all work collaboratively, and the council meets monthly. In addition to the council, on the outskirts of the council, clinicians and nurses meet regularly to actively discuss the day-to-day management of individual patients. So, the council is a broader umbrella, where we are creating guidance on protocols and educational materials that we give to both patients and clinicians. Outside the scope of the council, we as clinicians are meeting regularly and discussing these patients."

Targeting preeclampsia

CommonSpirit has also developed quality improvement toolkits to address preeclampsia, she says. "We know that preeclampsia is an independent risk factor for cardiac disease, which may occur during a pregnancy but can also occur decades after a pregnancy. This is why we like to target preeclampsia because it is a common adverse pregnancy outcome that we are seeing and rates of it are increasing. A lot of that has to do with the fact that women are having children later in life, and we know that anyone who has a baby past the age of 35 is at a slightly higher risk of having preeclampsia. The other reason we are focusing on preeclampsia is that many of these moms are coming into pregnancies with many common risk factors for high blood pressure outside the scope of pregnancy, and preeclampsia impacts blood pressure."

The health system is providing education about preeclampsia, Bond says. "The way from a quality improvement perspective we have been able to tackle preeclampsia is by providing education not only to the patients but also to the clinical staff. The way we have been able to do this successfully for the patients is we have created a 'passport.' That passport goes over signs and symptoms of how preeclampsia may present. It also goes over the common risk factors. In addition, it goes over how to track your blood pressure during pregnancy and after pregnancy. One thing many people do not realize is that when it comes to preeclampsia, it can occur in the post-partum period, usually upto six weeks post-partum."

Providing preeclampsia education to clinicians is pivotal, she says. "The first group of clinicians preeclampsia patients are seeing when they come to the hospital are emergency physicians. So, there is a large value in educating our emergency room providers. One of the questions we have them ask is, 'When was your last pregnancy?' If your last pregnancy was within a year, and you are coming in with signs and symptoms that are concerning for a cardiac condition, it could be related to that pregnancy. We have come a long way in providing education to our emergency medicine providers; and, similarly, we have provided education to our inpatient internal medicine providers—our hospitalists. It is important to highlight that this education is not just in the inpatient setting, it is also in the ambulatory setting. That is where this education has been targeting our obstetricians."

Standardizing care and protocols

Standardizing care and protocols for maternal health is essential, Bond says. "Data has shown that standardizing care and standardizing protocols can ensure that all of our patients are receiving the same level of care. More importantly, standardizing care and standardizing protocols can ensure that patients have access to the most current research and best practices."

Standardizing care and protocols helps address disparities in maternal health, she says. "It is important to highlight the fact that we have a maternal health crisis in the United States, and we know that this crisis disproportionately is affecting women of color and women who come from lower socioeconomic status. Unfortunately, one driver of this situation is there is implicit bias. So, if we remove the potential for implicit bias by standardizing care and creating protocols that are available for anybody regardless of race, ethnicity, or socioeconomic status, our hope is that we will be able to make a change and decrease poor outcomes."

Virtual care for rural patients

To help reach patients who struggle with healthcare access, CommonSpirit is providing virtual care for rural patients, Bond says. "We are targeting rural areas for telemedicine because we know those areas are where we have the majority of maternal care deserts. A maternal care desert is where you have limitations in obstetric care. Not only do they have limitations in obstetric care, but they also have limitations in specialty care such as cardiologists who focus on high-risk pregnancies."

Using telemedicine for patients in rural areas is good for patients and clinicians, she says. "It has been phenomenal because it allows us to reach the patient, it is convenient for the patient, and it can be convenient for clinicians. Through these visits, patients can access all levels of care that they may not already have available in their communities. More importantly, we can work with physicians who are more local to the patient to try to provide them guidance and co-manage patients."

Wake Forest Health Network is experiencing workforce shortages of clinical and nonclinical staff.

Workforce shortages are the primary challenge of managing Wake Forest Health Network, the president of the medical group says.

Russell Howerton, MD, is president of the medical group and senior vice president of clinical operations at Atrium Health Wake Forest Baptist. A practicing surgeon, he previously served as chief medical officer of Wake Forest Baptist Health.

Wake Forest Health Network employs about 500 physicians and advanced practice practitioners.

Howerton recently talked with HealthLeaders about a range of issues, including physician engagement, the challenges of serving as senior vice president of clinical operations at Atrium Health Wake Forest Baptist, and clinical care predictions for 2023. The following transcript of that conversation has been edited for brevity and clarity.

HealthLeaders: What are the challenges of leading the Wake Forest Health Network?

Russell Howerton: Emerging from the pandemic, our greatest challenge has been the workforce at either end. Staffing the non-provider workforce and securing adequate resources for our teams to deliver the expectations we have of them has been a great challenge. At the other end, provider recruitment, retention, and burnout have been major factors.

We have learned a great deal and done a great deal to develop our pipelines and recruiting processes for the non-provider staff—clinical and nonclinical, front desk, and the backend. We have always had partnerships with those who produce that element of the workforce,  but over the past couple of years, we have had to redouble our focus and intensify our efforts to strengthen those partnerships. We are not the only healthcare entity in the market for those individuals—it is ferociously competitive. We are gaining ground, but we are not where we want to be.

HL: How have you risen to the challenge of recruitment and retention in your provider workforce?

Howerton: There are many components of recruiting physicians and advanced practice practitioners. Of course, striving to have market compensation is always a core tenet—it is necessary, but it is not sufficient. Today, it is our perception that meeting the needs of physicians to feel an appropriate balance of autonomy and being securely nested in a larger system that insulates them from some of the vagaries of business practices is the task. In either direction, you can go off the rails. Certainly, you can insulate them a great deal, but you do not want to become too controlling of their daily lives and clinical activities. We feel we are striking an appropriate balance.

We are not as fully staffed as we would like, and we continue to face challenges recruiting primary care physicians. There are many new entrants and new models in the market, not just our traditional competitors. We have all recently watched primary care models for CVS and Amazon.

Creating the work environment that promotes physician engagement is a retention strategy. We also want to be the best place to work.

HL: What are the primary efforts you have in place to address burnout?

Howerton: You need to ease the barriers to giving good care. As an analogy, part of leadership's job is to make giving clinical care feel like a fish swimming downstream with the tide, not having to swim upriver against the tide simply to deliver the care that your professional standards call you to do. For better or worse, the complexities of modern care delivery and organizational structure manage to put a lot of obstacles in the way of giving clinical care. We are trying to address those obstacles.

Russell Howerton, MD, president of Wake Forest Health Network and senior vice president of clinical operations at Atrium Health Wake Forest Baptist. Photo courtesy of Atrium Health Wake Forest Baptist.

HL: What are the primary elements of physician engagement?

Howerton: Listening is essential, along with conveying that something was heard. When you listen, you will often hear much more than you can address. Physicians express broad concerns from promoting world peace to not having the parking lot swept often enough at a practice. You need to listen, hear, and act whenever possible on as many issues as possible.

HL: You serve as senior vice president of clinical operations. What are the challenges of serving in this role?

Howerton: I am responsible for several business lines and subsidiaries. I help oversee Wake Forest outpatient dialysis—we are the eighth-largest provider of patient dialysis in the nation. We operate more than 20 sites around our part of the state. It's an interesting business. It is like the hospital business in that it requires staff in place every day to care for the patients. Again, we have had an intense challenge of maintaining adequate staff to offer the services we need to provide, and the dialysis population is a non-elective population. They need to have their care whether you have staff or not.

Compared to the physician group, there is a much smaller pipeline of available individuals with knowledge in dialysis. We are using some of the same mechanisms used in large facilities but there are relatively few travelers in the dialysis world. We are actively recruiting overseas even though the lead time to onboard someone from an overseas environment is many months—it is still an overall more favorable investment than travelers.

To rise to this workforce challenge at the dialysis centers, we have adjusted our pay scales and we have broadened our recruitment searches. There is a higher labor cost in the nation today to get dialysis in real dollar terms than there was pre-pandemic. We do not envision that going away. We seek to find efficiencies and improvements in other aspects of the model.

HL: Do you have any clinical care predictions for 2023?

Howerton: I believe we will learn how telehealth will fit into the long-term model of healthcare. It clearly has a place we would not have imagined if you had asked us in January of 2020 before the pandemic.

I predict that the end of the public health emergency and the variety of approaches to the waivers and regulations that have allowed us to adopt a care model during the pandemic will lead to confusion for a couple of years.

HL: You have a clinical background as a surgeon. How has this clinical background helped you serve in physician leadership roles?

Howerton: Surgery requires a leader of a team to get the rest of the team to work together toward a common goal. That leadership skill is generally translatable to administrative leadership roles. I have a personal belief that the currency of leadership is the confidence of those you help lead that you, the leader, has confidence in them to do the job. The daily work of leadership is to build this confidence in those you help to lead, so that when you need to draw upon it, you can, and everyone can succeed.

Related: The Exec: 'All Providers Need to Reinvent Themselves in Some Way'

Workforce shortages contribute to several patient safety concerns this year.

ECRI and its affiliate, the Institute for Safe Medication Practices, have identified the Top 10 patient safety concerns of 2023 in a new annual report.

Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark report To Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.

The Top 10 patient safety concerns of 2023 according to ECRI and the Institute for Safe Medication Practices are as follows:

1. Pediatric mental health crisis

Pediatric mental health has reached crisis proportions, Marcus Schabacker, MD, PhD, president and CEO of ECRI, said in a prepared statement. "Even before COVID-19, the impact of social media, gun violence, and other socioeconomic factors were causing elevated rates of depression and anxiety in children. The challenges caused by the pandemic turned a bad situation into a crisis. We're approaching a national public health emergency."

Children are now at increased risk for suicide, the new annual report says. "The increase in children experiencing extreme anxiety and depression has led to an increase in suicidal ideation, with more young people age 12 to 25 presenting to the emergency department (ED) for suspected suicide attempts. Although adolescent suicide attempts had decreased during spring 2020, the mean weekly number of ED visits for suspected suicide attempts among those age 12 to 17 was 22% higher in summer 2020 and 39% higher during winter 2021 compared with the corresponding periods in 2019."

2. Physical and verbal violence against healthcare staff

Only law enforcement and security personnel face more workplace violence than healthcare workers, according to the annual report.

The Joint Commission has made workplace violence against healthcare workers a top priority, the annual report says. "In January 2022, Joint Commission accreditation standards began requiring leadership to develop and enforce a workplace violence prevention program. Joint Commission also states that effective workplace violence programs encourage reporting incidences of threatening language and verbal abuse in addition to physical abuse."

3. Clinician needs in times of uncertainty surrounding maternal-fetal medicine

When the U.S. Supreme Court overturned Roe v. Wade, which made maternal-fetal medicine a matter of state law, the high court created uncertainty for clinicians and their patients, the annual report says. "Although some states with abortion bans allow abortions to save the life of or prevent harm to the pregnant patient, there is often little guidance on where the line is. If clinicians wait too long, patients may suffer serious harm."

4. Impact on clinicians expected to work outside their scope of practice and competencies

Healthcare organizations have legal and ethical obligations to make sure clinical staff work within their scope of practice and competencies, but these obligations are being tested in several ways, the annual report says. "Many healthcare workers are still asked to step outside these boundaries, especially during public health emergencies and other societal circumstances such as staff shortages and turnover, increased patient volume, supply chain disruption, and rural facility closings."

5. Delayed identification and treatment of sepsis

Timely diagnosis and treatment of sepsis, which is the leading cause of death in hospitals, is crucial, the annual report says. "Intravenous antimicrobials should be administered immediately—ideally within an hour of recognition—for patients with shock and possible sepsis and for patients with a high likelihood of sepsis (including those without shock). Antimicrobials should be administered within three hours for patients with possible sepsis without shock."

6. Consequences of poor care coordination for patients with complex medical conditions

Care coordination is pivotal for patients with complex needs such as multiple chronic conditions because they often face care fragmentation, higher healthcare utilization, and worse health outcomes than other patients, the annual report says. "Improved care coordination can help mitigate these patient safety risks and preventable errors associated with common coordination pitfalls, including interprofessional communication, interoperability of health information technology (IT), medication reconciliation, test tracking and follow-up, and care transitions."

7. Risks of not looking beyond the "five rights" to achieve medication safety

The "five rights" of medication safety are right patient, right drug, right dose, right route, and right time, but they are insufficient on their own, the annual report says. "Failure to back up the five rights with high-leverage strategies and actionable procedures—or to identify which system processes failed when medication errors occur—undercuts medication safety."

8. Medication errors resulting from inaccurate patient medication lists

Inaccurate patient medication lists often occur because a patient is no longer taking a drug or a drug is omitted from the list, and healthcare organizations should have a robust system in place to address the problem, the annual report says. "Multidisciplinary medication reconciliation teams should review current processes, identify gaps and opportunities for improvement, and lead process design and redesign within the healthcare facility or practice. Team members should include executive leadership, physician champions, pharmacists, discharge planners, IT personnel, and patient safety and quality staff."

9. Accidental administration of neuromuscular blocking agents

Neuromuscular blocking agents paralyze skeletal muscles during mechanical ventilation, and they can be deadly when administered to patients who are not on a ventilator. According to the annual report, there are several causes of accidental administration of these medications, including look-alike packaging, unlabeled and mislabeled syringes, syringe swaps, and residual drug left in intravenous tubing.

10. Preventable harm due to omitted care or treatment

According to the annual report, missed care has several negative consequences, including complications such as pressure injuries, increased length of stay, and decreased patient satisfaction. "Some of the most common predictors of missed care include inadequate staffing levels; increased workload; poor work environment; limited staff experience, education, or competency; lack of material resources; poor communication; poor care transitions; limited skills mix of staff on the unit; and lack of teamwork," the report says.

Related: ECRI: Healthcare Organizations Must Address Racist Behavior in the Workplace